We carried out this announced inspection on 4 March 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a CQC inspector who was supported by a specialist dental adviser.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this practice was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this practice was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this practice was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this practice was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this practice was providing well-led care in accordance with the relevant regulations.

Background

Mydentist – Narborough Road South - Leicester is in Braunstone Town, and provides mostly NHS and some private treatment to adults and children. At the time of our inspection, the practice was accepting new NHS patients.

There is level access with a ramp for people who use wheelchairs and those with pushchairs. Car parking spaces are available on the road near to the practice. Blue badge holders can park directly in front of the premises.

The dental team includes three dentists, four dental nurses (three of whom also cover receptionist duties), two dental hygienists, a cleaner and a practice manager. The practice has two treatment rooms; one on ground floor level.

The practice is owned by a partnership and as a condition of registration must have a person registered with the Care Quality Commission as the registered manager. Registered managers have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run. The registered manager at mydentist – Narborough Road South – Leicester is the practice manager.

The practice was part of a corporate group which had a head office based in Manchester where support teams including human resources, IT, finance, health and safety, learning and development, clinical support and patient support services were based. These teams supported and offered expert advice and updates to the practice when required.

On the day of inspection, we collected six CQC comment cards filled in by patients.

During the inspection we spoke with two dentists, two dental nurses / receptionists, the practice manager, a regulatory officer and the area development manager who attended from the provider’s head office. We looked at practice policies and procedures, patient feedback and other records about how the service is managed.

The practice is open: Monday and Thursday from 9am to 6pm, Tuesday from 9am to 7pm, Wednesday from 9am to 5.30pm and Friday from 9am to 5pm.

Our key findings were:

• The practice appeared clean and well maintained.
• The provider had infection control procedures which reflected published guidance.
• Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
• The practice had systems to help them manage risk to patients and staff.
• The provider had suitable safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
• The provider had thorough staff recruitment procedures. The practice had access to support from a dedicated human resources and recruitment team based within the company’s head office.
• The clinical staff provided patients’ care and treatment in line with current guidelines. We noted however, that one of the dentists did not use rubber dam or record young patients’ basic periodontal examinations (BPE) until they were 13 years old. This was not in line with guidance.
• Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
• Staff were providing preventive care and supporting patients to ensure better oral health.
• The appointment system took account of patients’ needs.
• The provider had effective leadership and culture of continuous improvement.
• Staff felt involved and supported and worked well as a team.
• The provider asked staff and patients for feedback about the services they provided.
• The provider dealt with complaints positively and efficiently.
• The provider had suitable information governance arrangements.

There were areas where the provider could make improvements. They should:

• Review the practice’s protocols for the use of rubber dam for root canal treatment taking into account guidelines issued by the British Endodontic Society.
• Review guidance regarding basic periodontal examination (BPE) from the British Society of Periodontology.
• Review the practice’s protocols to ensure audits of radiography are undertaken at regular intervals to improve the quality of the service. Practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated.